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Complications of Cholecystectomy: Risks of the Laparoscopic Approach and Protective Effects of Operative Cholangiography: A Population-Based Study

Fletcher, David R. MD, FRACS*; Hobbs, Michael S.T. DPhil, FRACP; Tan, Patrick MBBS, FRACS; Valinsky, Liora J. BSc(Hons), MPH; Hockey, Richard L. BSc; Pikora, Terri J. BHSc; Knuiman, Matthew W. PhD; Sheiner, Harry J. MS, FRCS, FRACS§; Edis, Anthony MD, FRCS, FRACS§

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Background Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced.

Methods Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors.

Results After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury.

Conclusion Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.

From the Department of *Surgery, University of Western Australia and Fremantle Hospital, the †Department of Public Health, University of Western Australia, the ‡Department of Surgery, Royal Perth Hospital, and §The Mount Private Hospital, Perth, Australia

Correspondence: David R. Fletcher, MD, FRACS, University Department of Surgery, Fremantle Hospital, P.O. Box 480, Fremantle WA 6160, Australia.

Accepted for publication November 11, 1998.

© 1999 Lippincott Williams & Wilkins, Inc.